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Insurance denial

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Hi everyone,

I am a 2 time survivor In 2003 I had a lumpectomy, radiation, chemo and aromatase inhibitor for 10 years. Recurrence in 2012 in same left breast and opted for masc with reconstruction ( I had lost my husband a month later so wasn’t thinking too clearly) Anyways now finally looking for symmetry. Having a reduction, lift and Lipo on right breast. My insurance Cigna is denying the Lipo I know of the Women health and cancer right act would protect me with this denial.

I will file an appeal but was hoping to see if anyone has experience with this.

thank you so much and good health to all!

Joann

Comments

  • peregrinelady
    peregrinelady Member Posts: 416
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    I had to pay for the liposuction that was done during the revision (fat grafting) part of my DIEP reconstruction. The plastic surgeon said that it was optional because insurance did not cover it. It was about $2,000.

  • moderators
    moderators Posts: 8,187
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    Hey there, @joannweb! We wanted to share two articles from our website that might provide some insight into reconstruction and navigating health insurance challenges. Here are the links: Managing Your Health Insurance and Breast Reconstruction Surgery and Health Insurance. We hope you find them helpful, and please feel free to reach out if you have any questions or need further support.

    Wishing you all the best!

    The Mods


  • maggie15
    maggie15 Member Posts: 999
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    Hi @joannweb , Unfortunately some insurance companies consider fat grafting “experimental / investigational” while others will pay for it. It is possible to appeal that reason by showing the procedure is "medically necessary" for function rather than cosmetics citing medical publications and your health record. Contact your plastic surgeon's office to see if they have ever been able to successfully appeal that type of ruling and if they think it could be done in your case.

    I have filed six successful appeals with one of the denials "experimental/investigational" but not for reconstruction. That one was for trigeminal neuralgia laser surgery since my medical condition precluded the SOC surgery. My burn surgeon had successfully appealed this type of denial before and published a case study about my success so it could be used as ammunition by future patients.

    The first step would be to get a copy of the current medical utilization criteria for breast reconstruction from Cigna since that gives you the detailed information you need to base the appeal on. Filing a successful appeal can be a long process; internet search skills and enough of a scientific background to understand medical papers helps. A few of my appeals have been slam-dunks (post procedure denial of Oncotype and bc tumor surgical pathology) while others took up to a year. All the best!

    https://www.plasticsurgery.org/documents/Health-Policy/Reimbursement/insurance-2015-autologous-fat-grafting-breast.pdf

  • joannweb
    joannweb Member Posts: 4
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    Thank you all for your very useful information! I have Cigna which I think isn’t great to begin with.

    i can pay out of pocket $2000 for the liposuction on my right side. Not sure how I can spin it to be medically necessary.

    @pwregrinelady were you happy with your decision of the Lipo?

  • peregrinelady
    peregrinelady Member Posts: 416
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    Yes, I am happy with the result, but I will say that it was very painful as my whole lower back was bruised and it was done outpatient so there was no aftercare. My plastic surgeon made it sound like the reconstruction would not be complete without the fat grafting. I think they look more rounded with the liposuction and more natural looking. Good luck!

  • sedonadreaming
    sedonadreaming Member Posts: 12
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    I am glad I found this thread. My plan is for right single mastectomy with immediate DIEP reconstruction along with lift/ fat grafting on opposite side for symmetry. I’ll check with insurance before finalizing my plan.

  • vlnrph
    vlnrph Member Posts: 493
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    Do keep in mind that the best way for these companies to profit is by denying claims! Be sure to appeal as Maggie describes above. I was successful 4/4 times. A phone conference resulted in reimbursement for my wig which was actually a “cranial prosthesis”. Two others were in person at an office with their lawyer, a doctor plus someone else who called us.

    Both were probably designed as intimidating scenarios however I knew what my benefits were. They had to allow follow-up MRIs due to my diagnosis. They agreed but then dragged their feet on sending me an approval letter, delaying my scan by an extra month. Another situation involved coverage of a lymphedema machine for which I had prior authorization.

    Since my attempts to demonstrate that to them fell flat, I filled out a simple form that our state insurance commissioner provides on line. That judgment resulted in fines plus interest. Finally, because I had a genetic panel billed as only a BRCA test, for which I met eligibility requirements, they tried to evade their responsibility for that. Don’t give up. You CAN win.